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Covid-19 vaccination in children, adolescents, and young adults: how can we ensure high vaccination uptake?

After a rapid start, the pace of the United Kingdom’s (UK) covid-19 vaccination programme has slowed down while the UK still faces high infection, hospitalisation, and death rates, and a more transmissible Delta SARS-CoV-2 variant. Now that vaccination of children aged 12-15 has started, it is essential to achieve a high uptake of vaccination in this group, and also in young adults, to both protect them and to move the UK closer towards population level immunity. [1,2] Despite two doses of Pfizer-BioNTech, Moderna, and AstraZeneca vaccines offering good protection against the Delta variant—with Pfizer-BioNTech and AstraZeneca vaccines between 92-96% effective in preventing hospitalisations—many young people remain unvaccinated by choice, raising their risk of infection, hospitalisation, and long-term complications from covid-19. [3-5]

The UK population is among the most willing to receive a covid-19 vaccine; as of 11 October 2021, over 49 million individuals (85.6% of people aged 16 and over) had received at least one dose of a covid-19 vaccine. [6,7] However, the covid-19 vaccination programme—the largest ever launched by the NHS—is reaching a “demand” ceiling in adolescents and young adults, finding itself well behind other Western European countries, and hampering efforts to achieve population level immunity. If vaccination uptake is also slow in 12-15 years old children, this will further hinder efforts to reach population immunity.

Vaccination rates in younger people are lower and increasing more slowly than was seen in older age groups when they were first offered vaccination. [1,8] According to the Office for National Statistics, 14% of those aged 16-17 years, 10% of those aged between 22-25 years, and 9% of those aged between 18-21 years consider themselves “hesitant” compared to 4% observed across all other age groups. [5] This mirrors concerning findings from the USA which demonstrate that one in four of those aged between 18 and 25 “probably will not” or “definitely will not” receive a covid-19 vaccine, despite their heightened infection risk in recent months. [9] Given their increased tendency to socialise, strategies that improve vaccine acceptance in adolescents and young adults remain essential to control the pandemic globally as well as in the UK. [10]

Historically, vaccine hesitancy exists on a spectrum and is listed by the WHO as one of the top 10 global health threats. [11] The groups that are among the currently most affected by the virus are also the ones with the lowest vaccination rates. [12] With ideal conditions for SARS-CoV-2 to spread, the risk of emergence of “super variants” that could potentially escape vaccines and jeopardise the health of the most vulnerable in society remains a risk. Vaccine hesitancy in young people in the UK may be further increased by the delay in approving vaccination for 12–15 year-olds, with the UK starting vaccination later than many other European and North American countries. The message from the UK’s Joint Committee on Vaccination and Immunisation (JCVI) that covid-19 vaccination in this group offers only “marginal benefits” will also have contributed to this, with many parents and children questioning why they should be vaccinated if this is the case. [13] The benefits and potential risk from vaccination will therefore need to be discussed carefully with children and their parents to dispel any unwarranted negative views. [14]

This has been successfully done in Portugal; despite Portuguese parents not being safe from vaccine misinformation and disinformation, the country has managed to emerge as the world’s vaccination front-runner, with 86% of its population vaccinated (98% of whom are aged 12 years and over). [15] Its successful vaccine rollout is, in part, attributed to the country’s comprehensive monitoring system; vaccine compliance is monitored nationally by healthcare facilities, schools, daycare centres, summer camps, and other child institutions, allowing the country to develop and tailor educational information to hesitant parents or parents known to have refused a vaccine in the past. [16] This has generated favourable conditions for paediatric immunisation across the country.

Concerns about side effects are an important factor in vaccine hesitancy in children, adolescents, and young adults, particularly the risk of condition such as myocarditis. [9] Although rare, the myocarditis and pericarditis reports in adolescents and young adults, following the administration of Pfizer-BioNTech and Moderna vaccines, will have amplified fears of vaccines in this group. [17] However, the risk of developing complications, such as blood clots and myocarditis, from covid-19 illness remains greater than the risk from vaccines. [18] Genuine concerns about the side effects of vaccines should be addressed by academics and clinicians proactively listening to young people, and sharing risks and benefits in a manner that aligns intention with action. [19] It is also essential that moving forwards, the UK’s covid-19 vaccination programme is embedded in primary care to create a cost-effective, sustainable infrastructure for vaccine delivery; and to avoid making the many mistakes that were made in other parts of the covid-19 response, such as Test and Trace and the Nightingale Hospitals. [20]

To offset optimistic bias, including adolescents and young adults perceiving the risk of disease being lower than the risk of receiving a covid-19 vaccine, communication should speak to mechanism of action, effectiveness, and safety relevant to these age groups and the wider societal benefits of vaccination in protecting their older family members, and vulnerable friends and colleagues. [10,21] Further, public health messaging will be more effective if the benefits of controlling the pandemic, including freedom to attend festivals, sporting events and entertainment venues, as well as the ability to travel are reinforced. Targeted health messaging and public education campaigns will also require harnessing social media, schools and universities to counter the covid-19 infodemic. [10] To increase vaccination rates, messages should be tailored for families financially burdened by the pandemic, families with lower parental education and incomes, and adolescents and young adults with adverse childhood experiences. [10]

While the risk of severe disease and death from covid-19 is lower in young people, high infection rates and low vaccination rates mean this group remains vulnerable to long covid and its debilitating symptoms, regardless of the symptoms shown during their covid-19 infection. [9] With the majority of covid-19 deaths occurring in those aged 75 years and over throughout the pandemic, a youthful sense of invincibility will be an important barrier to overcome; young adults need to be mindful that although their symptoms may not be as severe, 57%, 39% and 30% of individuals have stated that long covid has negatively impacted their wellbeing, ability to exercise and ability to work, respectively. [22,23] Recent evidence suggests more people expressed fear and concern about the risk to health of those close to them. [24] Therefore, emphasising the protection that vaccines offer to those particularly vulnerable will likely have a positive effect on adolescents and young adults and their parents.

The pandemic is a “collective action problem,” requiring personal responsibility and responsible communication by governments and public health authorities that break through optimistic bias without prompting feelings of anxiety. The UK’s mixed messages on mitigation measures including face masks and working from home are likely to provide a false sense of security that discourages vaccination uptake at a time when infection rates remain much higher in the UK than other European countries. The race between vaccinations and mutations requires consistent, clear, and data-based messages that dispel misinformation, and promote informed decision-making, civic awareness, voluntary cooperation and a sense of collective purpose. This will improve vaccine uptake in all sections of the population, including children, adolescents, and young adults, at a key time when vaccination is being extended in many countries to younger age groups.

Tasnime Osama, Honorary Clinical Research Fellow in Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @itasnimeo

Mohammad S Razai, NIHR In-Practice Fellow in Primary Care, Population Health Research Institute, St George’s University of London. Twitter @MohammadRazai

Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @Azeem_Majeed

Competing Interests: None declared. 

Acknowledgements: AM is supported by the NIHR Applied Research Collaboration NW London. MSR is funded by the NIHR as an In-Practice Fellow. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

This article was first published by BMJ Opinion.

References:

  1. GOV.UK. Vaccinations in the UK 2021 doi: Available from: https://coronavirus.data.gov.uk/details/vaccinations
  2. CIDRAP. Youth, Delta variant behind UK COVID surge. 2021 doi: Available from: https://www.cidrap.umn.edu/news-perspective/2021/06/youth-delta-variant-behind-uk-covid-surge
  3. Yale Medicine. Comparing the COVID-19 Vaccines: How Are They Different? . 2021 doi: Available from: https://www.yalemedicine.org/news/covid-19-vaccine-comparison
  4. GOV.UK. Vaccines highly effective against hospitalisation from Delta variant. 2021 doi: Available from: https://www.gov.uk/government/news/vaccines-highly-effective-against-hospitalisation-from-delta-variant
  5. Office for National Statistics. Coronavirus and vaccine hesitancy, Great Britain: 26 May to 20 June 2021. 2021 doi: Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/coronavirusandvaccinehesitancygreatbritain/26mayto20june2021
  6. Imperial College London. Covid-19: Global attitudes towards a COVID-19 vaccine. 2021
  7. GOV.UK. Daily summary. Coronavirus in the UK. 2021 doi: Available from: https://coronavirus.data.gov.uk/
  8. Publich Health England.  COVID-19 vaccine surveillance report – week 29. 2021
  9. S. Leigh. Vaccine Hesitancy in Young Adults May Hamper Herd Immunity. UC San Francisco. . 2021 doi: Available from: https://www.ucsf.edu/news/2021/07/420991/vaccine-hesitancy-young-adults-may-hamper-herd-immunity
  10. Afifi TO, Salmon S, Taillieu T, et al. Older adolescents and young adults willingness to receive the COVID-19 vaccine: Implications for informing public health strategies. Vaccine 2021;39(26):3473-79.
  11. World Health Organization. Ten threats to global health in 2019. 2019 doi: Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019
  12. Public Health England. SARS-CoV-2 variants of concern and variants under investigation in England 2021
  13. Salisbury H. Helen Salisbury: Official hesitancy is not helping. bmj 2021;374
  14. Majeed A, Hodes S, Marks S. Consent for covid-19 vaccination in children. bmj 2021;374
  15. The New York Times. In Portugal, There Is Virtually No One Left to Vaccinate 2021 doi: Available from: https://www.nytimes.com/2021/10/01/world/europe/portugal-vaccination-rate.html
  16. Fonseca IC, Pereira AI, Barros L. Portuguese parental beliefs and attitudes towards vaccination. Health Psychology and Behavioral Medicine 2021;9(1):422-35.
  17. Centers for Disease Control and Prevention. Myocarditis and Pericarditis Following mRNA COVID-19 Vaccination. 2021 doi: Available from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html
  18. Oxford University. Risk of rare blood clotting higher for COVID-19 than for vaccines 2021 doi: Available from: https://www.ox.ac.uk/news/2021-04-15-risk-rare-blood-clotting-higher-covid-19-vaccines
  19. Dubov A, Phung C. Nudges or mandates? The ethics of mandatory flu vaccination. Vaccine 2015;33(22):2530-35.
  20. Hodes S, Majeed A. Building a sustainable infrastructure for covid-19 vaccinations long term. bmj 2021;373
  21. Razai MS, Chaudhry UA, Doerholt K, et al. Covid-19 vaccination hesitancy. bmj 2021;373
  22. Office for National Statistics. Coronavirus (COVID-19) latest insights: Deaths. 2021 doi: Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19latestinsights/deaths
  23. Office for National Statistics. Coronavirus and the social impacts of ‘long COVID’ on people’s lives in Great Britain 2021 doi: Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronavirusandthesocialimpactsoflongcovidonpeopleslivesingreatbritain/7aprilto13june2021
  24. Antonopoulou V et al. Which factors may help increase COVID-19 vaccine uptkae in England? . 2021 doi: Available from: https://research.ncl.ac.uk/behscipru/outputs/policybriefings/PRU-PB-011%20PRU%20covid%20vaccine%20policy%20brief%20study%204%20300421.pdf

Be aware of the overlap in symptoms between colds and Covid-19

During the previous winter (2020-21), rates of colds, flu and other respiratory infections were very low across the UK because of social distancing and other infection control measures. Now that these measures have largely stopped, we are seeing an increase in respiratory infections.

The symptoms of a cold can typically include a blocked or runny nose, sore throat, headache, cough , loss of smell, sneezing and muscle aches. Many of these symptoms can also occur in people with a Covid-19 infection. Now that most adults in the UK have been fully vaccinated with two doses of a Covid-19 vaccine, when people do contract Covid-19, it is often with milder symptoms that can overlap those from a cold. This means that for many people with these kinds of symptoms, a Covid-19 test will be needed to separate the two conditions.

There will be a lot of scope to confuse the symptoms of colds and Covid-19 during the winter. The message for the public should be to always be cautious if you have symptoms of a cold, get a test when appropriate, and limit interactions with people outside your household until you are better.

You can read more about this issue in this Daily Mirror article.

Patient-initiated second medical opinions in healthcare

A second medical opinion is a medical decision-making tool for patients, physicians, hospitals and insurers. For patients, it is a way to gain an additional opinion on a diagnosis, treatment or prognosis from another physician. Physicians seeking another colleague’s opinion may refer a patient to another consultant to gain further advice. Many health insurers mandate second opinion programmes to reduce medical costs and eliminate ineffective or suboptimal treatments. Hospitals may also require second reviews as part of routine pathology, radiology reviews or for legal purposes. consultant to consultant referrals. Patients in primary care may also request an opinion from a second specialist when unhappy with the opinion from the first specialist.

We carried out a systematic review to summarise evidence on (1) the characteristics and motivating factors of patients who initiate second opinions; (2) the impact of patient-initiated second opinions on diagnosis, treatment, prognosis and patient satisfaction; and (3) their cost effectiveness. The reivew was published in BMJ Opinion.

Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions.

The review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-044033

Will the NHS survive without GPs?

That rhetorical questions like the recent one posed by some in the media are even asked shows how deeply ill-informed and distorted the discourse on healthcare has become in the UK. Any dispassionate observer would know that GPs are the bedrock of the NHS; and without GPs the NHS will collapse. Here are just a few home truths: GPs in England manage a wide array of acute and chronic health conditions through over 300 million patient consultations each year compared to 23 million A&E visits. [1] GPs issue about one billion prescriptions annually and have delivered two thirds of phase 1 covid-19 vaccinations. [2]

The public already know how hard their family doctors are working to care for them. Despite the challenges of the pandemic, soaring demand, a shrinking GP workforce and a workload that has often become unmanageable, GPs have one of the highest public satisfaction ratings of any public service in the UK. In a survey in July 2021, an overwhelming majority of patients (83%) rated their overall experience of GPs as good and 48.2% rated their experience as “very good.” [3] By contrast, in a comparable UK survey of adult hospital inpatients for overall experience in 2019, 48% of patients gave a score of 9 or 10 (good or very good).

General Practitioners are highly skilled professionals who manage extremely complex medical conditions with limited access to resources, including high-tech diagnostics, available in secondary care. GPs not only treat medical conditions, but through their longitudinal and relationship-based care, also manage non-medical problems. One in five patients consults general practitioners for primarily social problems rather than medical. [4]

Much of the reputation of the NHS in international league tables (ranked number one health system out of 11 countries in 2017 and fourth in 2021) rests on the efficiency and excellence of its primary care. [5,6] A year’s worth of GP care per patient costs less than an A&E visit and less is spent on general practice than on hospital outpatients. GP practices were paid an average £155 per patient in 2019/2020, but the average cost of treatment in A&E, without the cost of ambulance or overnight admission, could be up to £400. Yet for the past two decades funding for hospitals has grown twice as fast as for general practice. [1] Further, between 2005/6 to 2017 the proportion of money spent in general practice fell from 9.6% to 8.1%.

Recent surveys show two in three patients (67%) are satisfied with the appointment times available to them and 67% find it easy to get through to GPs. [3] General practice had to quickly adapt during the pandemic to provide safe care by fulfilling their public health role in protecting their patients and the community from covid-19. More patients now consult in primary care than the pre-pandemic with over half these appointments face to face. [7] There are however serious problems and challenges that patients face including access to GP services and the quality of their care.

The public deserves honesty and courage from political leaders, commentators, and policymakers. Rather than skirting over facts by blaming GPs, who currently deliver over 31 million appointments per month in England, politicians need to be honest with the public on what kind of healthcare the population needs and what they are currently getting.

The UK spends less per capita on healthcare than other comparable countries (0.27% of GPD compared to an OECD average of 0.51%). [8] The UK also has one of the lowest numbers of doctors in leading European countries relative to its population, behind Estonia, Slovenia, and Latvia (about 2.9 per 1,000 people, compared with an average of 3.5 doctors across the OECD). The OECD figure also includes hospital doctors which have grown. In England, between 2004 and 2021 the number of hospital consultants has risen by 83% (from 28,141 to 51,490). On the other hand, the number of permanent and locum qualified GPs in England has fallen with fewer GPs in December 2020 than the year before. The Nuffield Trust analysis shows the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s with the shortage particularly marked in some English regions.

Lack of an adequate GP workforce is only part of the problem. The recent media attacks on GPs highlights a total disregard for a workforce already at breaking point. A record number of GPs are seeking mental health counselling, and many are leaving the workforce by taking early retirement or working abroad. Therefore, the question that we must ask is: if the NHS collapses, who will notice it? Those with platforms to undermine the NHS will be unlikely to notice it. The elite has the means and resources to seek healthcare outside the NHS and even abroad, but for everyone else the collapse of the system will be catastrophic.

The solution starts with putting a stop to attacks on GPs and the NHS by politicians and the permanently outraged sections of the media. Secondly, to achieve health outcomes comparable to other OECD countries, the NHS must tackle workforce shortages and the decline in quality of services. [9] The increasing health needs of an ageing population and the growing demand for better healthcare require more than alienating and undermining a workforce on whom the NHS depends. General practice could make better use of non-medical professionals such as social prescribers to reduce the workload and people could be sign-posted to services in the community without a GP referral. The administrative burden on primary care is also unsustainable and must be reduced; for example, by suspending CQC inspections. We also need a dialogue between the public, professionals, and politicians about what kind of primary care system they want in the UK; with plans then backed up with the appropriate level of investment. Health systems with a strong primary care infrastructure can achieve better health outcomes, improve patient experience, and reduce pressures elsewhere in the NHS. This should be the objective that we strive to achieve.

Mohammad Sharif Razai, NIHR In-Practice Fellow in Primary Care, St George’s University of London. Twitter: @mohammadrazai

Azeem Majeed, Professor of Primary Care & Public Health, Department of Primary Care & Public Health, Imperial College London @Azeem_Majeed

This article was first published in BMJ Opinion.

References:

  1. NHS England. Primary Care. Available from: https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/primary-care/ (accessed 19 September 2021)
  2. Patient Information. Where to get medication in an emergency. Available from: https://patient.info/news-and-features/where-to-get-medication-in-an-emergency (accessed 19 September 2021)
  3. NHS England.  GP Patient Survey 2021. Available from: https://www.england.nhs.uk/statistics/2021/07/08/gp-patient-survey-2021/ (accessed 19 September 2021)
  4. Advice Services Alliance. The role of advice services in health outcomes: evidence review and mapping study. 2015. https://www.thelegaleducationfoundation.org/wp-content/uploads/2015/06/Role-of-Advice-Services-in-Health-Outcomes.pdf.
  5. The Commonwealth Fund. Mirror, Mirro 2017. Available from: https://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/ (accessed 19 September 2021)
  6. The Commonwealth Fund. Mirror, Mirror 2021. Available from: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly (accessed 19 September 2021)
  7. Royal College of General Practitioners. College sets record straight on face-to-face GP appointments. August 2021. Available from: https://www.rcgp.org.uk/about-us/news/2021/august/college-sets-record-straight-on-face-to-face-gp-appointments.aspx (accessed 19 September 2021)
  8. The Health Foundation. The UK spends less on capital in health care than other comparable countries. 2019. Available from: https://www.health.org.uk/news-and-comment/charts-and-infographics/the-uk-spends-less-on-capital-in-health-care-than-other-comp (accessed 19 September 2021)
  9. Papanicolas I, Mossialos E, Gundersen A, Woskie L, Jha A K. Performance of UK National Health Service compared with other high income countries: observational study  BMJ  2019;  367 :l6326 doi:10.1136/bmj.l6326

Why MPs and journalists need to speak to their local general practices

The UK’s MPs and journalists repeatedly say they want “GPs to get back to work”. But instead of asking this, they need to speak to staff in their local general practices to understand what the issues are that are causing problems for patients in gaining access primary care services, whether via a face to face appointment or by telephone. The number of GPs per person in England has declined in recent years. At the same time, the volume and complexity of care has increased steadily year-on-year. These problems have been compounded by the rebound in primary care activity following an initial fall at the start of the Covid-19 pandemic. Many GPs report that they and their teams are now dealing with a record level of work.

In this context, asking GPs to “get back to work” is insulting for them and their teams. GPs made major changes in the way they work at the start of the Covid-19 pandemic to protect patients – with little additional support from NHS England – and are now struggling with long-term shortages of doctors and other staff, and unsafe levels of workload. If GPs and journalists spoke to the staff in their local general practices, they would understand these issues better and also be more aware of potential solutions. Better-informed MPs and journalists might then actually be able to apply pressure on the government to urgently address the many problems that face NHS general practices in England, and bring an end to the culture of “sticking plaster solutions” that NHS England has offered in recent years.

Consent for covid-19 vaccination in children

Now that covid-19 vaccination of children in the UK is starting, it is essential that the legal basis of consent for a medical intervention in this group are well understood

A Court of Appeal ruling on 17 September 2021 overturned a previous High Court ruling, and decided that parental consent is not needed for children under 16 to take puberty blockers. This reaffirms, again, that the responsibility to consent to treatment depends on the ability of medical staff to decide on the capacity of under 16 year olds to consent to medical treatment.

The timing is auspicious. Just a few days before, the four UK Chief Medical Officers recommended that all healthy children aged 12-15 should be “offered” a single covid-19 vaccine, with a booster likely in the Spring 2022. Until now, the only children in this age group offered a vaccine have been those with certain medical conditions, or those living in a household with a clinically vulnerable adult. With a mass vaccine campaign for children now starting, the issue of consent for vaccines in this group has been headline news.

Reaching the decision about vaccinating 12-15 year olds in the UK has been an interesting process. The Joint Committee on Vaccination and Immunisation (JCVI) have deliberated, awaiting evolving evidence, and have scrutinised the data available purely on a risk benefit basis for the vaccine itself. The chief medical officers looked at wider effects to society, and given that modelling suggests that vaccination of 12-15 year olds can save so many lost days of school, infections and associated transmission, they recommended vaccination to the government, but leaving the final decision to politicians.

Now that covid-19 vaccination of children in the UK is starting, it is essential that the legal basis of consent for a medical intervention in this group are well understood by parents, carers, health professionals—and most importantly by children. Teenagers who are aged 16 or 17 are deemed under English law to be able to give their own consent for vaccination. But what about 12-15 year olds?

Ideally, for children who are aged 12-15, covid-19 vaccination would be given with the approval and support of their parents. This is likely to improve children’s confidence in covid-19 vaccines, and help ensure a high and rapid take-up of vaccination. With the vaccine programme due to start in schools before the end of September, parents are being sent out consent forms, along with NHS information leaflets. Explaining such a finely balanced decision in child friendly terms will be challenging. A survey by the UK Office for National Statistics reported that around 90% of parents were in favour of vaccinating children. Surveys also show good confidence in covid-19 vaccines among children and young adults (but usually at a lower level than among older people).

But despite high overall support for covid-19 vaccination, there will be families where children and parents may have very differing opinions about its risks and benefits. For example, some parents may be strongly opposed to covid-19 vaccination, but their child may have a different view. The opposite situation is also possible whereby the parents are in favour of vaccination but the child is opposed to vaccination.

In such circumstances, the NHS and the responsible clinicians have to decide if the child is competent to make their own decision about covid-19 vaccination. This is known as Gillick competence following a court case in the 1980s between Ms Victoria Gillick and the NHS about consent to treatment for children under 16. The court case eventually made its way to the House of Lords, which ruled that “As a matter of Law, the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.” The ruling is valid in England and Wales.

Whether a child is Gillick competent is assessed using criteria such as the age of the child, their understanding of the treatment (both benefits and risks) and their ability to explain their views about the treatment. If deemed to be Gillick competent, the child can make their own decision about a medical intervention such as covid-19 vaccination.

There may also be situations in which two parents disagree about covid-19 vaccination. If the child is not Gillick competent, then a decision needs to be made about which parent’s views take priority. In a court case in 2020 where two parents disagreed about vaccination for their children, the Judge ruled that vaccination was in the best interests of the child because this is what the scientific evidence suggests. In the court case, the judge (Mr Justice MacDonald) deferred deciding about any future covid-19 vaccination because of the “early stage reached with respect to the covid-19 vaccination programme.” However, now that vaccination has been approved by the UK government and is supported by bodies such as Public Health England, it is highly likely that a court would rule in favour of covid-19 vaccination where two parents had opposing views.

None of these issues are new, and the current HPV vaccination programme has tested many of the issues surrounding vaccination in this age group already. However, the scale and speed of the covid-19 vaccination may be far more contentious—particularly given the finely balanced risk-benefit profile, the small risks of myocarditis, and the vaccine hesitancy already noted in younger people.

It is important that parents, teachers, and healthcare professionals understand the risk and benefits of covid-19 vaccination for children, so that we can support them in reaching an informed decision. We need to respect the ability of our children, whose lives and education have been so greatly affected and disrupted by the pandemic, to reach their own conclusions given the evidence available. Where there is a disagreement between a child and their parents or legal guardians regarding any medical treatment, healthcare professionals must feel confident in judging Gillick Competence and the issues surrounding capacity to give consent.

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed

Simon Hodes, GP Partner, Watford, UK, Twitter @DrSimonHodes

Stephen Marks, Consultant Paediatric Nephrologist, Great Ormond Street Hospital, London, UK

Competing Interests: We have read and understood the BMJ policy on declaration of interests. AM and SH are GPs and have supported the NHS covid-19 vaccination programme. We have no other competing interests.

Acknowledgements: AM is supported by the NIHR Applied Research Collaboration NW London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

This article was first published in BMJ Opinion.

GPs should not be made scapegoats for political failings

A recent article in the Daily Telegraph article asked “If the GPs went on strike, would anybody notice?” The article claimed that no one would notice if GPs went on strike and the author suggested that making all GPs salaried, forcing them to work longer hours, would help improve general practice for patients. The author quoted “a now retired GP in his 90s from Bristol who continued doing locum work until five years ago,” who apparently said, “Many GPs are using covid-19 as an excuse for not providing good clinical services. Being able to opt out of night/weekend cover and only working two or three days a week have caused the demise of general practice to the detriment of patients.”

As GPs we have worked throughout this pandemic often face-to-face in the most basic of personal protective equipment (PPE), and we were disheartened to read this piece.

GPs and their teams have played an essential role throughout the pandemic. GP teams in England alone deal with over 300 million contacts each year. General Practices have been running community hot covid clinics, and supporting NHS 111 and the Covid Clinical Assessment Service (CCAS). We are supporting 5.5 million patients on NHS waiting lists, who are often in severe pain and in need of extra support, as well as supporting about 1 million patients with the effects of long covid, and adapting to new ways of working enforced by a global pandemic. In addition, our teams have delivered the majority of covid vaccinations thus far. We are currently being asked to recall our most clinically vulnerable patients for their third covid booster vaccination. All this has been achieved despite the proportion of the NHS budget spent on NHS general practice and the number of GPs per person both declining in England in recent years.

We are already seeing that any small reduction in GP access causes rapid spill over into Emergency Departments, so just imagine if there were no GP service at all. The NHS would collapse. When GPs began to pull back from the covid-19 vaccination programme because of the mass vaccine sites taking over, for example, the rate of vaccination slowed—especially in the hardest to reach groups—and complaints increased from patients unable to access vaccine appointments.

If we look at prescriptions, GPs and their teams issue a vast number every year. If another part of the NHS tried to take on this work, an army of people would be needed—doctors, pharmacists, and administrative staff. Many higher risk medications need careful monitoring and regular review. Patients on most regular medication also require medication reviews, checks (e.g., blood tests, measuring blood pressure) to monitor safe prescribing and prevent drug interactions, and to deal with queries and frequent shortages and changes of medicines. The efficient systems that GPs have developed for prescribing means that they issue many prescriptions that would be given by hospital specialists in other countries.

Moreover, every patient seen in secondary care generates a letter, often with requests for GP teams to follow up patients, monitor their treatment, arrange blood tests, or prescribe.

The work of a GP can be incredibly rewarding as we build long term relationships with people over years, and there is strong evidence for the benefits of continuity of care (for both patients and the care provider).  GPs are true “generalists” and the uncertainty of undifferentiated illness is stressful, especially when working remotely. GPs in the UK work at a higher level of intensity than elsewhere in Europe. GPs in the UK have the shortest consultation times in Europe, and UK GPs tend to see more than twice the safe recommended number of patients per day.

BMA appointment data show huge increases in activity over the past 18 months. Yes, there are more telephone appointments and fewer face to face appointments, but this is the same in all sectors of society—and the same for both community and hospital care. It should come as no surprise, or make headline news, because remote working is in line with direct government policy and is there to protect both patients and staff from a highly infectious and potentially lethal virus. It is especially important to protect the many vulnerable individuals we look after in general practice, in a time when there are over 30,000 covid-19 cases reported daily in the UK.

Despite political promises for an additional 6000 additional GPs in England by 2024, there has been a reduction in numbers rather than an increase. While there is a clear link between ratios of family doctors and life expectancy, the number of patients per practice is now 22% higher than it was in 2015, and the GP workforce has not grown with this demand. As a result, there are now just 0.46 fully qualified GPs per 1000 patients in England, down from 0.52 in 2015, which, when added to growing demand from the rising number of people living with complex chronic illness and poverty along with an ageing population, means that primary care is in a desperate situation. GP turnover is higher in deprived areas further exacerbating health inequalities.

Demand on general practice is increasing, while at the same time general practices are struggling to recruit staff. The current deepening GP crisis that we are facing is having widespread effects on patient care nationwide. The current crisis long predated covid-19, but the pandemic has highlighted the large cracks in the NHS. GP teams should not be made scapegoats for the political failings, under-funding, and shortages of essential staff, which are the root cause of the issue.

General practice is often described as the “Bedrock of the NHS,” and the NHS Five Year NHS View states that “if General Practice Fails the NHS Fails.” We must be mindful of that, and instead of blaming GPs for the current crisis, look at what can be urgently done to alleviate the crisis.

Simon Hodes, GP partner in Watford, GP trainer, appraiser and LMC rep. Twitter: @DrSimonHodes

Frances Mair, Norie Miller professor of general practice. Twitter: @FrancesMair

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed

This article was first published in BMJ Opinion.

Covid infections are high in the UK – these are the reasons why

Covid-19 case numbers remain high in the UK. In this article, I discuss why this is and why vaccines are working as expected, and protecting us from serious illness and death.

What is a breakthrough infection?

No vaccine is 100% effective against preventing infection. An infection in a fully vaccinated person is sometimes described as a breakthrough infection because the infective agent has “broken through” the protection from infection provided by the vaccine.

How common is Covid-19 infection in fully vaccinated people?

Data from Public Health England show that the Covid-19 vaccines used in the UK reduce the risk of  infection by about 70-90% in people who are fully vaccinated, so vaccines prevent the majority of people who are vaccinated from becoming infected. However, some people who are fully vaccinated will still become infected. Over time, as the number of people in the population who are vaccinated increases, a greater proportion of infections will occur in vaccinated people. It is possible that the immunity from vaccination will weaken over time, with breakthrough infections therefore becoming more common, which is why the government is now considering giving booster doses of vaccine to some people.

How serious is Covid-19 infection in vaccinated people?

Research shows that vaccines are very effective in reducing the risk of serious illness from a Covid-19 infection, with around a 95% reduction in the risk of hospitalisation and death. However, some people who are vaccinated will still have a serious illness. As with infections in unvaccinated people, the risk of a serious illness is highest in the elderly and people with medical problems such as diabetes and obesity.

What makes a breakthrough infection more likely?

The more people you come into close contact with, the more likely you are to have a breakthrough infection. People whose work involves a lot of contact with other people, such as health professionals, will be at greater risk of a breakthrough infection. The risk of a breakthrough infection is also higher in people with weak immune systems because vaccines work less well for them. The risk of becoming infected with Covid-19 is highest in poorly-ventilated, crowded indoor spaces. To reduce your risk of infection, you should as far as possible, avoid these kinds of settings. A face mask can provide some protection from infection, particularly if you use a higher specification mask such as FFP2 mask.

How do new variants like delta effect the risk of infection?

The delta variant of the coronavirus that spread across the world in 2021, and which is now responsible for nearly all cases of Covid-19 in the UK, is more infectious than other variants. Vaccines will be a little less effective at preventing infection from the delta variant than the variants that were previously circulating in the UK. However, vaccines still remain very effective at preventing serious illness, hospitalisation and death, even against infections caused by the delta variant. So far, we have not yet come across a variant of the coronavirus against which vaccines are ineffective.

How well are vaccines working in the UK?

Vaccines are working very well in the UK. Around 81% of people aged 16 and over have been fully vaccinated. Public Health England estimates that around 24 million infections, 144,000 hospitalisations and 112,000 deaths have been prevented by vaccination. Without vaccines, the number of cases, hospitalisations and deaths in the UK would be much higher than now, requiring further Covid-19 restrictions and lockdowns to control the pandemic. It is vaccines that have allowed the government to relax these restrictions and let people to live more normally.

First published in the Daily Mirror.

Risk of Covid-19 in shielded and care home patients

Early in the Covid-19 pandemic, the elderly and people who were clinically extremely vulnerable were asked to shield to reduce their risks of Covid-19 infection and its complications. We evaluated the effectiveness of shielding in a study published recently in the journal BJGP Open.

We found that Covid-19 rates were much higher in the shielded group compared with non-shielded group (6.5% vs 1.8%). The increase in risk of infection in the shielded group persisted after adjustment for a wide range of factors in a Cox proportional hazards regression model.

We also found that Covid-19 rates were seven times higher in people living in care homes; and were also higher among people from ethnic minorities, those living in poorer areas, and in people with long-term medical conditions such as respiratory disease.

Our results suggest that shielding alone is not enough to protect clinically vulnerable people and that vaccination, along with suppressing community infection rates, remains the best way to protect these patients from the risk of serious illness and death from Covid-19.

Our results also refute suggestions that the UK could have avoided lockdowns by shielding vulnerable groups, whilst allowing society to otherwise function normally. This policy would probably have led to even higher infection, hospitalisation, and death rates in vulnerable people.

DOI: https://doi.org/10.3399/BJGPO.2021.0081

Having multiple sclerosis and depression is associated with an increased risk of early death

Depression is common in people with multiple sclerosis (MS), and a new study from our research group shows that people with both conditions are more likely to die over the next decade than people with just one or neither condition. The study was published in the September 2021, online issue of Neurology, the medical journal of the American Academy of Neurology. The study also found that people with MS and depression have an increased risk of developing vascular disease such as heart attack and stroke.

“These findings underscore the importance of identifying depression in people with MS as well as monitoring for other risk factors for heart disease and stroke,” said lead author Raffaele Palladino, MD, PhD, of Imperial College of London in the United Kingdom. “Future studies need to be conducted to look at whether treating depression in people with MS could reduce the risk of vascular disease as well as death over time.”

The study involved 12,251 people with MS and 72,572 people who did not have MS. We looked at medical records to see who developed vascular disease or died over a period of 10 years. At the start of the study, 21% of the people with MS had depression and 9% of the people without MS had depression.

We found that people with both MS and depression had a mortality rate from any cause of 10.3 per 100,000 person-years. Person-years take into account the number of people in a study as well as the amount of time spent in the study. The mortality rate for people with MS without depression was 10.6, for people who had depression without MS it was 3.6 and for people with neither condition it was 2.5.

Once we adjusted for other factors that could affect the risk of death such as smoking and diabetes, we found that people with both conditions were more than five times more likely to die during the next decade than people with neither condition. People with MS without depression were nearly four times more likely to die than people with neither condition and people with depression without MS were nearly twice as likely to die.

For the risk of vascular disease, the rate for people with both MS and depression was 2.4 cases per 100,000 person-years; 1.2 for people with MS without depression; 1.3 for people with depression without MS; and 0.7 for people with neither condition.

After adjusting for other factors, we found that people with both conditions were more than three times as likely to develop vascular disease as people with neither condition.

“When we looked at the risk of death, we found that the joint effect of MS plus depression equaled more than the effect for each individual factor alone — in other words, the two conditions had a synergistic effect,” Palladino said. “A total of 14% of the effect on mortality rate could be attributed to the interaction between these two conditions.”

Materials for this blog were provided by the American Academy of Neurology.

Journal Reference:

  1. Raffaele Palladino, Jeremy Chataway, Azeem Majeed, Ruth Ann Marrie. Interface of Multiple Sclerosis, Depression, Vascular Disease, and Mortality: A Population-Based Matched Cohort Study. Neurology, 2021; 10.1212/WNL.0000000000012610 DOI: 10.1212/WNL.0000000000012610